Outpatient palliative care, nurse training and advanced care planning for high-risk geriatric patients: Three best practices in providing end-of-life care

Having effective end-of-life conversations with patients, honoring their wishes and supporting the whole family is critically important to providing compassionate, high-quality healthcare.  SCAN Health Plan and UCLA School of Medicine partnered to identify best practices in caring for high-risk, geriatric patients with end-of-life care needs and multiple chronic conditions.  Three medical groups identified best practices focused on outpatient palliative care, improved nurse training and advanced care planning.  Additionally, recording patient wishes in the EHR ensures that the whole care team understands and can act on this information. 

Best Practice Astreamlined referrals to palliative care home-visits for patients with serious life limiting illnesses.  Visiting clinicians conducted goals of care discussions, managed symptoms, provided emotional and social support as needed.  Data collected six months after intervention showed a 37.8% decrease in cost per member and numerous testimonials attesting to the value of the program.

Best Practice Bfocused on training nurses in the “Ask, Tell, Ask” model of improving communication skills, clear explanation of prognosis and guided decision-making.  Initial data shows increased palliative care referrals and increased nurse job satisfaction.

Best Practice C trained facilitators to complete advanced care plans with patients enrolled in a comprehensive care program (CCP) to ensure patient centered care from an interdisciplinary team of physicians, nurses and social workers in various care settings.  Initial data indicates better quality of care at the end of life and reduced costs and utilization.

Further study on long-term outcomes, patient satisfaction, utilization, sustainability and scalability of these interventions is needed.